Minnesota Physician • December 2020 by Minnesota Physician Publishing

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DECEMBER 2020

PHYSICIAN

THE INDEPENDENT MEDICAL BUSINESS JOURNAL

Volume XXXIV, No. 09

Administrative Overload Breaking down whatâ&#x20AC;&#x2122;s breaking down BY TODD ARCHBOLD, LSW, MBA

ur nation boasts one of the most innovative and sophisticated health systems in the world. The administrative infrastructure required to support this system has led to a bloat in costs, with diminishing returns. We have the most expensive healthcare system in the world, yet without commensurate outcomes. The U.S. life expectancy at birth ranks 34th among other developed nations.

Corporate Culture in Health Care Accountabilities of Governing Boards BY DANIEL K. ZISMER, PH.D.

or many community hospitals and health systems employed physicians now drive the lionâ&#x20AC;&#x2122;s share of clinical care, and by extension the economics and financial performance of the organization. For some, physician services organizations actually define the brand and the strategic differentiation of the organization. Physician services organizations can take a number of forms. Regardless of corporate structure, they are composed of employed physicians, other licensed healthcare providers and support staff serving a range of required functions; all operating under Corporate Culture in Health Care to page 104

According to a report from the Commonwealth Fund, in 2018, the U.S. spent 16.9 percent of gross domestic product (GDP) on health care, nearly twice as much as the average OECD country. The American Medical Association reports that healthcare spending has reached $3.6 trillion in recent years and could nearly double within the next decade. The reality is that innovation is expensive, but is how we are doing it efficient? A study done by Definitive Healthcare ranks Minnesota no. 19

Administrative Overload to page 124

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DECEMBER 2020 MINNESOTA PHYSICIAN

DECEMBER 2020

Volume XXXIV, Number 9

COVER FEATURES Corporate Culture in Health Care Accountabilities of Governing Boards

Administrative Overload Breaking down what’s breaking down

By Daniel K. Zismer, Ph.D.

By Todd Archbold, LSW, MBA

DEPARTMENTS CAPSULES .................................................................................. 4 INTERVIEW .................................................................................. 8

ON-DEMAND

Creating a WellCare Ecosystem Craig Samitt, MD, MBA Blue Cross Blue Shield of Minnesota

HEALTH INFORMATION TECHNOLOGY......................................... 14 Digital Therapeutics An emerging field

By Megan Coder, PharmD, MBA, and Christina Nyquist SENIOR CARE............................................................................. 16 The Age Friendly Network Making communities livable for seniors

By Will Phillips SURGERY................................................................................... 18 Turning the Table Advancements in nerve repair saved surgical career

By Patrick H. Smock, MD BEHAVIORAL HEALTH.................................................................. 20 Physician Moral Distress A reckoning with unmet needs

By By Timothy J. Usset, MDiv, MPH, Mike Koopmeiners, MD and Joshua T. Morris, PhD, BCC BEHAVIORAL HEALTH.................................................................. 24 An Epidemic Within a Pandemic System-Level Changes for Physician Wellbeing

By Michelle D. Sherman, PhD LP ABPP, Adam Sattler, PhD LP, Barbara Carver PsyD, LP, Rosean Bishop, PhD LP, Jennifer Nelson Albee, MSW, LICSW

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ART DIRECTOR______________________________________________________ Scotty Town, stown@mppub.com Minnesota Physician is published once a month by Minnesota Physician Publishing, Inc. Our address is PO Box 6674, Minneapolis, MN 55406; email comments@mppub.com; phone 612.728.8600;. We welcome the submission of manuscripts and letters for possible publication. All views and opinions expressed by authors of published articles are solely those of the authors and do not necessarily represent or express the views of Minnesota Physician Publishing, Inc. or this publication. The contents herein are believed accurate but are not intended to replace medical, legal, tax, business, or other professional advice and counsel. No part of the publication may be reprinted or reproduced without written permission of the publisher. Annual subscriptions (12 copies) are $48.00/ Individual copies are $5.00.

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Medical Cannabis Program Expands Qualifying Conditions The Minnesota Department of Health will add sickle cell disease and chronic vocal or motor tic disorder to its list of qualifying medical conditions for participation in the state’s medical cannabis program. The new qualifying conditions will take effect in August 2021. As in past years, MDH conducted a formal petitioning process to solicit public input on potential qualifying conditions and delivery methods for medicine. Throughout June and July, Minnesotans submitted petitions. Following that, the process then moved into a public comment period and a public review panel. One of the health problems sickle cell disease triggers is severe pain. “Giving sickle cell patients a more direct pathway into the medical cannabis program will permit them

a non-opioid option to manage their pain,” said Commissioner of Health Jan Malcolm. Minnesota’s medical cannabis program already has Tourette’s syndrome as one of its qualifying medical conditions. Vocal or motor tic disorder is distinct from Tourette’s syndrome in that patients experience only vocal or motor tics, where people with Tourette’s experience both vocal and motor tics. In addition to the two new conditions, MDH considered a petition for anxiety. That petition was rejected, but Commissioner Malcolm said that the agency will commit to a deeper look at the condition in the first part of 2021. “Anxiety is a broad term for a group of specific disorders,” said Commissioner Malcolm. “We want to dig into specific anxiety disorders more and move forward carefully. The large number of patient testimonials submitted during the petition process tells us there is something there. However, we want

to avoid unintended consequences – there is evidence that cannabis use can actually contribute to and make anxiety worse for some people.” This is the third time anxiety has been petitioned for the medical cannabis program. When the Minnesota Legislature authorized the creation of the state’s medical cannabis program, the law included nine conditions that qualified a patient to receive medical cannabis. The list now includes fifteen.

Center for Diagnostic Imaging Purchases Wisconsin Based Smart Choice MRI CDI has reached an agreement to purchase certain assets from Smart Choice MRI. CDI is adding former Smart Choice MRI locations in Appleton, De Pere, Kenosha and La Crosse to its existing Wisconsin network of outpatient imaging centers.

Do you have patients with trouble using their phone due to a hearing loss, speech or physical disability? Contact the Telephone Equipment Distribution Program for easier ways to use the phone. Phone: 800-657-3663 Email: dhs.dhhsd@state.mn.us Website: mn.gov/deaf-hard-of-hearing The Telephone Equipment Distribution Program is funded through the Department of Commerce – Telecommunications Access Minnesota (TAM) and administered by the Minnesota Department of Human Services.

DECEMBER 2020 MINNESOTA PHYSICIAN

CDI currently operates outpatient imaging centers in Appleton and Eau Claire, as well as six multi-modality imaging centers in Milwaukee through a partnership with Froedtert and the Medical College of Wisconsin. “We’re excited about expanding our presence in Wisconsin,” said Rick Long, CDI President and Chief Executive Officer. “We’ve had a long history of providing critical health care answers to patients and providers throughout the state, and these new centers help us expand access to our high-quality, high-value imaging services at a crucial time when people are seeking the convenience and safety of outpatient care.” Smart Choice MRI has closed its remaining locations in Minnesota, Wisconsin and Illinois. Patients seeking care at a Smart Choice MRI location are being offered appointments at nearby CDI locations. CDI

CAPSULES

has a well-established network of outpatient imaging centers in these markets that provide MRIs and a full range of other diagnostic imaging services and procedures. CDI is one of the nation’s leading providers of high-quality diagnostic imaging and interventional radiology services through its network of imaging centers, ambulatory surgery centers, and mobile imaging solutions. With more than 130 centers nationwide, CDI’s network includes 15 outpatient centers in the Twin Cities and two in Chicago. With the addition of the new locations in Appleton, De Pere, Kenosha and La Crosse, CDI now operates 10 centers in Wisconsin.

MDH Launches Text Contact Tracing Program In response to the rapid increase in COVID cases, the Minnesota Department of Health has included text messaging as part of the ongoing efforts to inform Minnesotans who have tested positive or come on contact with those who have. The new initiative will increase the effectiveness of existing contact efforts and help protect those most vulnerable. “Reaching every single person by phone who needs information is a monumental task,” said Minnesota Commissioner of Health Jan Malcolm. “Our staff and our partners in local public health and tribal health have done enormous work in this area, and will continue to do so. We ask all Minnesotans to do their part by answering the call, and we hope this text notification helps provide some notice and reassurance.” “We have information and resources to share with Minnesotans, but we understand that many people are wary of answering a phone call from a number they don’t recognize,” said Chris Elvrum, MDH project spokesperson. “Sending the text lets people know we’re going

to call and even tells them what number to expect the call from. Adding this tool boosts our chances of slowing the spread of COVID-19 by increasing the number of people who answer the call and successfully isolate themselves.” A text message will be sent to people identified as a case or the contact of a case to let them know that a case interviewer from state, local or tribal health departments will be calling to discuss their COVID-19 test results or potential exposure.

EmPATH offers Model for Emergency Mental Health Care M Health Fairview has announced a new model for outpatient mental health care, Emergency Psychiatric Assessment, Treatment, and Healing (EmPATH). Minnesota’s first EmPATH unit will open at M Health Fairview Southdale Hospital early next year, with more to follow across the M Health Fairview system. EmPATH offers ER patients in crisis immediate access to a team of mental health experts in a calming, living-room-style environment. After a quick ER triage process, patients with mental health or substance use disorder needs are guided to EmPATH. There, they will get compassionate care to stabilize their situation, reducing the likelihood that they will need to be admitted into a hospital’s inpatient psychiatric unit. In addition to rapid treatment, EmPATH providers will partner with each patient and the patient’s loved ones to develop a care plan. Teams will also provide connections to follow-up services, so that each person will leave with a roadmap for ongoing care. Emergency Medicine Physician and Psychiatrist Richard Levine, MD said, “Part of EmPATH’s effectiveness is that it establishes building blocks for future treatments patients will receive. The hope is that we can get more patients

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on the right path right away, so we are providing better short- and long-term care.” “A mental health hospitalization can be difficult, and it’s only appropriate when patients cannot reasonably care for themselves safely,” said Lewis P. Zeidner, PhD, M Health Fairview’s clinical director of behavioral healthcare providers. “It’s our job as mental health professionals to help our patients become self-sufficient. If patients can avoid hospitalization through use of other care models, then they can start using their new skills in their daily lives to build resilience. That level of individualized care isn’t always available in an emergency department. Nationally, 1 in 8 emergency room visits involve mental health or substance use conditions. Mental health patients aren’t the only people who stand to benefit from the introduction of EmPATH in the Twin Cities. Moving behavioral health patients

out of emergency departments and into EmPATH units will streamline patient flow, meaning people coming with other illnesses or injuries – from heart attacks to broken legs – will have faster access to emergency care.

Large Health Systems Post 3Q profits After huge losses in financial statement reports from the second quarter of 2020, the largest health systems in Minnesota had positive third quarters. Allina (over $50 million on over $1 billion in revenue) and Fairview (about $10 million on over 1.5 billion in revenue) have reported modest gains from the third quarter. Mayo clinic also reported profits (just under $300 million on just over $3.5 billion in revenue) and plans to return a portion of its CARES funding. Impacted by the executive orders around elective surgeries

and shutdown-related patient fear of going to see their doctors, the second quarter saw large health systems losing over $5 million a day. Other systems have yet to report third quarter earnings, however most systems report patient volume is close to 90% of pre-pandemic norms. CARES act financing has played a role in third quarter income. It is too early to predict the impact of the current spike in cases. Lessons learned from the initial response will mitigate some potential losses, as may additional federal funding. Concerns over staff shortages and burnout lend to the uncertainty of fourth quarter projections. All systems expect the losses of 2020 to present challenges for 2021.

Minnesota Oncology joins Mayo Clinic Care Network Minnesota Oncology and the Mayo Clinic announced last week

that Minnesota Oncology is the newest member of the Mayo Clinic Care Network. The Network is a group of independent health systems that have special access to Mayo Clinic knowledge, resources, and expertise. Minnesota Oncology is an independent cancer care practice with over 100 cancer care experts and eleven metro locations as well as a clinic in Waconia. The practice is part of The US Oncology Network, a practice management organization with over 1300 oncologists nationwide. “When our founding physicians —the early pioneers of oncology in Minnesota — joined forces to form what is now Minnesota Oncology , they understood the value of physicians working together to improve patient care. And today, we continue to build upon that belief as we join the Mayo Clinic Care Network,” says John Schwerkoske, M.D., president, Minnesota Oncology.

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Ryan Ellis

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“Minnesota Oncology and Mayo Clinic’s oncology and hematology teams have a long history of collaborating on patient care,” continues Dr. Schwerkoske. “Formalizing this collaboration in a clinically meaningful relationship enhances our commitment to improve the quality and delivery of health care to our community — expanding access to the highest quality of care while allowing patients to stay right here in the Twin Cities under the supervision of their established care team at Minnesota Oncology.” “Minnesota Oncology is a strong, high-quality regional organization that shares a patient-centered approach to cancer care. We look forward to being a resource and working together to benefit patients in the Twin Cities” said Mark V. Larson, M.D., enterprise medical director, Mayo Clinic Provider Relations. Through this relationship, Minnesota Oncology providers will have access to Mayo Clinic’s specialized knowledge and expertise, including its research, diagnostic, and treatment resources.

CMS Recognizes HealthPartners MSHO Plan An annual report from CMS on the quality of health and drug services for Medicare enrollees has just awarded the HealthPartners Minnesota Senior Health Options (MSHO) a 5 star rating. The report scores on a one to five star range based on a series of clinical and performance measures including quality of care, member experience, health plan administration and customer service. HealthPartners is the first and only plan in Minnesota to earn the top score, and one of three fully integrated dual eligible special needs plans (FIDESNPs) in the nation to receive 5 stars for 2021. “Earning a 5-star rating for MSHO is an incredible accomplishment, and I’m proud to be part of a team that works hard to achieve top performance that improves the health and well-being of our members,” said

Jim Eppel, HealthPartners executive vice president and chief administrative officer. “Excellence in health care matters. These impressive ratings mean we’re keeping members healthy and delivering on our promise of high-quality, affordable care.” MSHO enrollees are lower-income and have more medical conditions and disabilities. Their social determinants of health can present further challenges to improving the care experience and health outcomes for enrollees. HealthPartners offers unique benefits to eligible MSHO members including coverage for animatronic support pets, electronic tablets, light therapy lamps and caregiver support.

Davis Acquires Woodbury Medical Office Building Minneapolis-based Davis recently announced the acquisition of the 52,787 sq. ft Cornerstone Medical Building in Woodbury. This was part of closing on eight medical office buildings (MOBs) totaling 309,735 square feet during the first two weeks of December for a total of $112 million. Three of the properties were sold into the fund from existing Davis-affiliated partnerships and five were newly acquired from third parties. “This is just the start of what we expect will be a fund of 20+ medical office buildings totaling up to $240 million,” says Mark Davis, Founder and Managing Partner of the national healthcare real estate development, property management, brokerage and investment firm.

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INTERVIEW

Creating a WellCare Ecosystem Craig Samitt, MD, MBA Blue Cross Blue Shield of Minnesota As a payer, you have a fairly unique perspective on the pandemic. What are some of the most surprising things you have seen that you can share with physicians?

is that a transition to an ecosystem centered on wellness will put our industry back on track.

In our professional lifetime, we have not seen, or been taught, how to deal with one crisis − let alone many simultaneous ones. A pleasant surprise for me, both as a physician and payer, has been how much the local care delivery and business communities have rallied and worked in lockstep to care for the sick and needy, to keep employees safe, and to work hard to preserve jobs and protect livelihoods.

What evolution do you see in this field?

Many people say the employer-sponsored health insurance model is unsustainable.

The explosion of telehealth has been a major byproduct of the pandemic. What can you share about your plans around ongoing reimbursement for these services as well as experiences with your own Doctor on Demand program?

Some of the current thinking at BC/BS MN involves the idea of the health care ecosystem. Please tell us about this.

While we currently reference our industry as a Healthcare System, I’d prefer that we aspire

DECEMBER 2020 MINNESOTA PHYSICIAN

“...”

Our industry cannot be the barrier to progress.

“...”

I’ve long hoped that virtual care would become more of a mainstream option for care delivery, but would not have wanted that transformation to be fueled by a pandemic. In 2019, we paid about 65,000 telehealth claims, and through the first three quarters of 2020, we saw more than 2 million telehealth claims. Patient response to no-cost access for services offered by Doctor On Demand was tremendous. We will continue offering expanded virtual care benefits for members and pay parity with in-person visits for providers into 2021. Before extending the program further out into the future, we first want to assure that telehealth delivers all that patients hope and expect − more convenient, high quality, and over lower cost healthcare. Through telehealth and other improvements that are needed in our industry, we have an opportunity to pivot to value in response to this pandemic. We should not squander that chance.

to be something better. Let me call it a Wellcare Ecosystem. What if our industry truly lived the expression “an ounce of prevention is worth a pound of cure?” What if we rewarded prevention, avoidance, social health, mental health, wellness, eliminating systemic racism − everything we can argue is in the “ounce?” Similar to a rainforest, health care has a complex ecosystem with interdependent stakeholders that don’t all need to work in lockstep at the same time. Healthcare stakeholders need to be aligned around the same goals and incentives, with everything focused on delivering better care at a lower cost for patients and better health for our community. I believe our current system is unsustainable if left on its current course. The fewer that can afford health care, the fewer in our community that benefit. The more that industry stakeholders work in opposition, the more patients are caught in the middle. My hope

I’m a strong advocate for universal coverage, and believe that all Minnesotans should have access to high quality, affordable healthcare. To achieve this goal, and to preserve consumer choice, I’m hoping that we can adopt a “no wrong door” approach that offers high-value care options for all that want and need it. 180 million Americans are insured by employersponsored coverage today. While that amount may erode over time, many employers enjoy this model and view it as a key tool in attracting and retaining top talent. That said, the primary reason employer-sponsored health insurance is unsustainable is the rising cost of care. As such, I envision that we will see employers become more aggressive in working with plans and providers to use price transparency, innovation, technology, virtual care, selective networks, and other means to improve quality and drive down costs. Another problem involves hospital costs. How will the role of the hospital change, both in the metro and outstate?

From the start of the pandemic, we have witnessed the critical role that hospitals play in providing emergent and intensive care. Postpandemic, I predict we will see the role of hospitals in our ecosystem continue to change. As the population ages, there will be increasing demand for complex and emergent care and appropriate elective inpatient care. In the future, hospitals will likely address this growing demand not through additional bed capacity, but by safely and effectively shifting lower acuity, non-emergent, non-intensive care delivery to other venues, such as ASCs, doctor offices, patient homes and telehealth. As we have seen at Blue Cross via our growing partnerships with North, Allina, Mayo, Minnesota Oncology, Minnesota Healthcare Network and others, I envision that high-performing hospitals will

increasingly become population health companies − with an intensified focus on ambulatory, social and behavioral health as a complement to inpatient care. What work is BC/BS MN undertaking to address cultural diversity and systemic racism?

One of the challenges in our industry is we’ve been asked to − or forced to − stay in our lanes. As I mentioned previously, I believe systemic racism and cultural bias is part of the “ounce of prevention.” If we are to play a role in transforming healthcare, organizations like Blue Cross and Blue Shield of Minnesota need to be more than just a claims company, a sickness management company, and a payment company. Given that our strategic plan is all about reinventing our industry by reinventing ourselves, we are undertaking a bold and comprehensive portfolio of racial and health equity and diversity equity and inclusion efforts. In doing so, we are getting into the equity business, social determinants of health business, and racial justice business. While I don’t have the space here to add all that we’re doing, I’d be happy to fully share all that we’re doing for those that are interested. Needless to say, we aren’t being shy,

remaining silent, or avoiding risks in this space. We are taking bold action to advance true racial and health equity for our team, for those that we serve, and for our community at large. You have said that the biggest problem facing health care is the resistance to change. What can you tell us about this?

My hope is that all that we’ve been through in 2020 will lead to a fundamental reinvention of our industry. How is it possible that we can cost so much as an industry and yet preserve the gaps we’ve seen through this crisis? I’m referring to coverage gaps, care delivery gaps, equity gaps and others. If we come out of this crisis and see premiums rise, ongoing inequities, worsening coverage, or a return to a fee-for-service payment chassis, that would only compound the tragedy. Our industry cannot be the barrier to progress. We must be the drivers of reinvention of our own industry. Another concept you have put forth is the idea of becoming the “un-health plan”. What does this mean?

At a recent meeting, I heard someone appropriately point out that “if the healthcare

industry doesn’t propose change, change will likely be imposed.” I’ve long advocated for reinvention of our industry from the inside-out rather than awaiting disruptive innovators or regulations driving change from the outside-in. For me, reinvention isn’t incremental change. It requires transformation. So becoming an un-health plan isn’t about becoming modestly better. It’s about leading a paradigm shift that drives material improvement in patient satisfaction, access, quality and affordability. Are there any final thoughts you would like to share with physicians as we move into 2021?

In addition to my heartfelt thanks and gratitude, I wish our physician colleagues much health, safety, rest and healing heading into the New Year. Craig Samitt, MD, MBA is the President and CEO of Blue Cross Blue Shield of Minnesota. Since 2018 he has been responsible for overseeing the strategy and operations of the state’s first and largest health plan.

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3Corporate Culture in Health Care from cover

Culture in organizations of professionals is inextricably linked with the performance of the organization at all levels.

the health system’s governing board. The physician services organization is, by definition, an extension of a community health system’s mission and strategy, and is the legal responsibility of the governing board. The physician services organization provides a level of mission and business complexity that can challenge and perplex health system boards. Why? In part it’s because the physician organization often has no defined and articulated purpose in the organization. In fact for some organizations growth and development of the physician organization has been kept subrosa. It’s there, but it may lack formal organization, a distinct brand identity, there is no formal leadership structure with physicians in leadership positions, and the physicians of the organization have no defined institutional standing. By extension, the physician organization has no defined mission, strategy, business plan or intentionally defined and led culture.

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Before going deeper into the rationale for health system governing boards’ responsibility to understand and care for the culture of their physician organization in their health system, let’s start with a definition of culture.

Physicians are the economic, financial and clinical care flywheel of the organization.

It is this last point that should give health system governing boards pause and reason to ask the question of health system senior leadership “what is the state and status of the culture of our employed physician organization and what role does it play in our mission, strategy and overall success?” But why? There are very practical and sound mission and business reasons for the question. The short answer is, “it matters”.

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Defining Corporate Culture

“Culture is the foundation of intrinsic beliefs that bind and inspire the behaviors of people in organizations to pursue a mission with unity and purpose.” The culture of an organization is made manifest in its performance; its clinical care performance, the quality of the patient experience, its approach to mission responsibilities, how it treats its employees and how it ranks in comparison with other, similar, community health services providers.

How does this definition apply to physician organizations in health systems, and why does it matter to governing boards? The effective practice of medicine, as a component of health care delivery, is a “team sport”. The very practical rationale for why it should matter to governing boards is physicians are the economic, financial and clinical care flywheel of the organization. Their decisions, behaviors, and attitudes influence performance at multiple levels. They move freely through and across the organization daily. They interact with, direct, and influence the behaviors and attitudes of multiples of staff who provide and support patient care, and they are seen as formal and informal leaders of the organization. For many patients they are the face of the brand of the organization, and they exert considerable influence on the patient experience. Simply stated, the culture of the organization is affected and reflected by physicians employed by the health system. A practical example may help illustrate the point and importance. During a speech to a group of physicians employed by a health system, a heart surgeon, who was into his first year of employment, raised his hand to provide his perspective on the importance of culture. He shared; “When I came to join the physician group of the health system, I had visions of becoming a member of a unified, high-performing team. What I discovered is I joined a loose confederation of physicians practicing independently together. We are not a cohesive group with a shared vision and mission. As such, I decided that if I stayed I had to become comfortable with being a cog in a big machine; show up, do my work and go home.” It is important for members of governing boards to understand that physician organizations in health systems are not composed solely of physicians. Depending upon the size and clinical specialty composition of the organization, the number of non-physician employees, in the physician services organization will be multiples of the that of the employed physicians. The perspective for boards to internalize here is the physician organization will touch and influence the performance of hundreds, and perhaps thousands, of people in the organization. The culture of the physician services organization will have profound implications for the culture of the whole, and that culture will affect the performance of the organization.

The Psychology of Physician Service Organizations Physicians make their way to the employ of health systems by multiple paths. Some come with the acquisition of a local medical practice. Local physicians

may join as individuals, leaving a private practice for the employ of the health system. Physicians with years of experience are recruited to the health system from other external environments, domestic and foreign. Physicians fresh out of training programs, residencies and fellowships, will be recruited to the health system. Each shows up with varied histories, impressions, expectations and hopes related to the culture of the organization they’re joining. Those who are local, and join as a group by a practice acquisition, will bring their own expectations of culture, said and unsaid, ranging from “we have our own culture, leave us alone” to “the principal reason we wanted to join is we have a dysfunctional culture and we need someone to fix it”. At times, the physicians of the practice acquired will endure varying levels of responses from their own independent practice colleagues, ranging from dismissiveness, benign neglect, or even disdain for colleagues who “sell out”. In certain instances the independent physicians will lobby members of governing boards for “equal treatment” ensuring that the employed physicians are not unduly advantaged. The point here is that given how physician organizations in health systems begin and evolve, letting the culture “take care of itself “ is a leadership mistake. The first lesson of leading culture is every organization will have a culture, by design of default. The culture of the organization is the leaders’ choice. The need for understandings of culture goes to the level of the individual professional. Boards need to appreciate the employed physician as a highly trained, skilled and practiced professional. Physicians are, at once, members of teams, and are expected to be the at the tip of the accountability spear. An illustration of this complexity is in order here. When facing professional liability exposures, the physician organizations with the under-developed

cultures will run from their colleague facing the threat, those with the wellled and developed cultures will run to their colleague to provide support, counsel and the benefit of their own experience and advice. The individual physician requires a culture that supports the value of the team, while according the physician sufficient freedoms to exercise their professional judgement, along with reasonable sufficiencies of personal control over how they craft and development their personal practice style, within guidelines established by leadership of the group. Likewise, the system of rewards must meet a set of complex needs, wants and expectancies. Here the meaning of “rewards” goes far beyond the mundane; e.g., money and time off, to rewards derivative of affiliation with a strong culture, including the pride that comes with being a member of a respected organization with high community standards and status. In one study conducted by our team, the factor that most affected physicians’ evaluation of the state of the culture of the organization was “all physicians are held to the same quality standards”.

Governance and the Culture of the Physician Organization Our research shows that the people of the organization believe the culture of the organization is what the leadership wants it to be; for better or worse. While “leadership” may be defined variously, and for some it is an amorphous concept, there is no doubt that the governing board of a healthcare organization is defined legally and morally as the leadership body “in charge” of the organization, and while it may delegate the attending of culture to senior management, it is not in a position to abdicate Corporate Culture in Health Care to page 344

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11 8/6/20 11:15 AM

3Administrative Overload from cover

Patients are likely to experience most of their interactions with administrative staff who are supporting the care delivery processes. This will in the nation by the average cost per procedure, largely burdened by the range from medical receptionists, schedulers, patient accounts staff and more. administrative overload that is not mitigated by an economy of scale. While some of these models can help create more efficiencies for physicians, most often the processes that administrative staff Discussions about healthcare reform, support are driven by a response to external forces streamlining our systems, creating a single-party opposed to an improvement in patient care. These payer, and many other means to simplify access to outside forces include such things as changes in care are constant. All the while the administrative regulations, increased compliance expectations, overload of our health systems continues to Nearly 95% of job revenue cycle requirements, technology and more. increase. Most health care administrators are

growth in healthcare is

driven by compassion and desire to help people, Analyzing Non-Clinical Support in administrative jobs. but quickly find themselves lost in the minutiae The Medical Group Management Association of rote tasks that seem worlds away from patient (MGMA) was founded in 1947 to help identify care. This overload primarily comes in the form and promote best-practices in clinic management. of indirect processes and paperwork, usually The MGMA currently has more than 55,000 required by regulatory agencies and insurance members and their advocacy and resources have companies, not driven by administratorâ&#x20AC;&#x2122;s desire to control a hospital, been core to the functioning of many medical practices. Only a generation clinic or health system. The added layers of administrative duties continue ago the concept of a clinic administrator was seen as a threat to the fidelity to drive job growth, but not necessarily wages. A writer for the Harvard of patient care but today nearly 95% of job growth in healthcare is in Business Review estimated that over half of costs of healthcare are wages administrative jobs. for workers, while productivity has historically been worsening. While Despite administrative efforts to create efficiencies, health care delivery most people envision hospitals being run by doctors and nurses, and is fragmented and there are increasing numbers of layers of work. The result maybe a few administrators behind the scenes, the opposite may be true. is a system that is not well-engineered for our patients in terms of caring More than 60% of labor is non-clinical, and those jobs are fragmented for their whole self, throughout their needed cycle of care and conditions. across organizations, payer systems and delivery models. The main issues shown in epidemiological data that contribute to the rising costs of U.S. healthcare stem from our aging population, obesity, and the management of chronic diseases. Americans visit their doctors less often and are not as diligent about preventative measures such as lifestyle habits and regular screenings. The reality is that in order to support one physician, there is an everincreasing requirement of additional indirect duties that need to be performed by administrators. In some cases, these requirements even limit how much the physician can do (such as scheduling appointments, ordering labs and more). There are also increasing needs to support back-end operations such as supply-chain management and facilities maintenance. To help curb some of these costs, most clinic and hospital systems are members of group purchasing organizations (GPOs) designed to get greater discounts when ordering in bulk, through exclusive agreements. Discounts can be offered up front and savings can also be realized through confusing â&#x20AC;&#x153;sharebackâ&#x20AC;? programs. Oftentimes these GPOs are owned and managed by larger health systems as a separate business. While they are designed to save costs and create efficiencies, participation requires fees, sometimes exclusivity, and even then they require close administrative monitoring. It is not uncommon for members of the same GPO to receive different pricing and perks due to the constantly shifting and archaic way they are designed. Administrative burden can largely be attributed to the following areas:

Technology Our health systems utilize expensive technologies such as MRIs and specialized procedures more often than our peers in other countries. In addition to medical device technology, our systems are incredibly reliant on expensive electronic health information and practice management systems. Expenses to implement an electronic health record (EHR) systems can easily

DECEMBER 2020 MINNESOTA PHYSICIAN

the use and dissemination of health care information. In practice, compliance reach into the millions for a single hospital, and even into the billions for with HIPAA requires incredible costs in technology and staffing. large multi-hospital systems. The indirect costs and administrative burden beyond implementation is staggering. This includes training, security, Accreditation and Compliance maintenance, upgrades and more. By 2014 the federal investment into the Almost all major health systems work with an accrediting organization Health Information Technology for Economic like The Joint Commission, National Committee and Clinical Health (HITECH) Act had for Quality Assurance, or DNV GL Healthcare. already reached $25 billion. The EHR industry These organizations have CMS deeming authority now generates over $16 billion a year and offers which means earning their seal of approval also providers a baffling range of over 700 products. subsumes the CMS Conditions of Participation, Compliance with HIPAA The vision of easy and secure data-sharing and most other insurance companies. Surveys requires incredible costs in between systems and interoperability remains can be exhaustive and have direct costs associated technology and staffing. elusive for most providers. EHRs are also the most with participating in their programs, paying for prominent contributor to provider burnout. Many staff travel, and even for ongoing consultation. practice management systems aim to assist in The indirect costs far exceed the survey itself with meeting compliance standards, but the inevitable hospital teams that support and implement the need for ongoing integration and development is accreditation standards, educate staff, perform surprisingly complicated and in many cases even mock audits and more. While in general receiving formal accreditation cost-prohibitive. This means practices often compromise on true efficiency fundamentally aligns a health system with top standards, many areas of and quality process, for the sake of affordability. Therefore, the impact of compliance seem overly bureaucratic or redundant, and in some cases even changes in standards elsewhere in healthcare can create a dependence on unnecessary. A major complaint from many systems is the authority given technology, and subsequent costs of development. to the individual surveyors to interpret standards, which may feel different Billing and Insurance Related (BIR) between surveys. A health systems preparedness will likely still require This includes things like prior authorizations, claims submission and visits and audits from other insurance companies and local officials, such payment processing. While the Affordable Care Act (ACA) has helped extend insurance to millions more Americans, many are now experiencing Administrative Overload to page 324 the pains of being underinsured. Even for those who have insurance, there are high-deductible plans, copays, co-insurance, confusing networks â&#x20AC;&#x201C; all of which have increased the financial burden and stress for patients. This has had the same impact on health systems who are responsible for checking benefits, gaining tedious authorizations, submitting, processing and reprocessing claims. It is estimated that nearly 1 in 5 claims need to be reprocessed. According to a 2019 McKinsey & Company report, the U.S. could reduce administrative spending by 30 percent by automating and streamlining BIR processes. The revenue cycle process in healthcare has become increasingly more complicated and prone to errors that can leave guarantors with unnecessary financial responsibilities, and leave providers going unpaid entirely. Health systems must employ and train specialists to deal with all of these disparities within the revenue cycle including managing complex software with rulesengines that vary by payer, ensuring ongoing authorizations for hospital services, and keeping up to date on frequent regulatory changes. One of the most popularized examples of overload in this area are the compliance requirements of the Health Insurance Portability and Accountability Act (HIPAA). For the most part, people misunderstand the fundamental purpose of HIPAA â&#x20AC;&#x201C; which is to help make the exchange of private health information easy and safe to help in the delivery of highquality care, while mitigating fraud and abuse. In reality, an immense amount of time and energy of both providers and administrators goes into managing consents, disclosures, releases, and security. Most people have HIPAA backwards as this formidable law results in significant administrative burden and the threat of penalties. Ironically, Title II of HIPAA contains the Administrative Simplification provisions which are largely aimed at increasing the efficiency of the health care system by creating standards for

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HEALTH INFORMATION TECHNOLOGY

Digital Therapeutics An emerging field BY MEGAN CODER, PHARMD, MBA, AND CHRISTINA NYQUIST

s COVID-19 continues to impact health systems, lessons learned to date can assist in determining how to navigate ongoing challenges, and could lead to improvements in addressing ever-increasing levels of chronic disease, mental health, and opioid abuse. To build a stronger and more holistic health ecosystem, it is critical that technologies such as telehealth and remote monitoring become foundational components—along with the emerging field of digital therapeutics.

Defining DTx Still in a relatively early stage of formation, digital therapeutics (DTx) are a subcategory of digital health technologies that deliver therapeutic interventions directly to patients using evidence-based, clinically evaluated software to treat, manage, and prevent a disease or disorder. DTx provide patients, caregivers, and clinicians with access to new models of remote and on-demand care, with evidence-based treatment delivered through personal devices such as smartphones and tablets. DTx products must comply with ten rigorous patient-centered core principles and best practices (https://tinyurl.com/mp-dtx-best-practices) to

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ensure product integrity, user-centered designs, patient privacy, and validated clinical outcomes via randomized controlled trials and real-world evidence. All products claiming to be a digital therapeutic must: • Prevent, manage, or treat a medical disorder or disease. • Produce a medical intervention that is driven by software. • Incorporate design, manufacture, and quality best practices. • Engage end users in product development and usability processes. • Incorporate patient privacy and security protections. • Apply product deployment, management, and maintenance best practices. • Publish trial results inclusive of clinically meaningful outcomes in peer-reviewed journals. • Be reviewed and cleared or certified by regulatory bodies as required to support product claims of risk, efficacy, and intended use. • Make claims appropriate to clinical evaluation and regulatory status. • Collect, analyze, and apply real world evidence and/or product performance data. Many DTx products are used in concert with other devices, medications, or therapies to optimize patient care and health outcomes, while others may be used independently. Collectively these treatment options yield distinct, additive benefits to patients’ physical, mental, and behavioral health. In the United States, private insurers, pharmacy benefits managers, and employers are increasingly embracing digital therapeutic technologies to improve patient outcomes. As a result of observations from the COVID pandemic, three important things present expanded opportunities for digital therapeutics.

Underlying health disparities have resulted in unequal impacts. Minority populations in the United States have suffered from the COVID19 pandemic disproportionately. The Black community has the highest age-adjusted mortality rate in the United States from COVID, estimated at 3.8 times the rate for White populations. Native American and Hispanic populations experience similar disparities with estimated mortality rates 3.2 times and 2.5 times, respectively, that of White populations.

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The unacceptable impacts of COVID-19 on minorities parallels longstanding, well-documented health disparities within these communities. Using diabetes as an example, the rate of disease in Black adults is 60% higher than White adults, with Hispanics being 1.4 times more likely than White adults to die from diabetes. In the U.S., Native Americans account for the highest rate of diabetes, with one in six individuals receiving this diagnosis, and in some tribes as many as 60% of adults having Type 2 diabetes.

Mental health shortages have long persisted and may worsen through and following this national emergency.

1.7 to 2.0 points. DarioHealth’s DTx product showed a 50% reduction in hypoglycemic events over 24 months, plus a 60% drop in hyperglycemic events over a year. Voluntis’ Insulia, a DTx product that generates personalized insulin titration recommendations, showed at four months that twice as many patients with Type 2 diabetes achieved an A1c <7 versus a control group (29.8% vs 12.5%).

Prior to COVID-19, 115 million Americans lived in a mental health care shortage area. This number is expected to increase as Americans continue adjusting to unfamiliar “new normals,” while already overburdened health care providers face new demands on their time and address outstanding patient backlogs. Research by the Well Being Trust indicates the aftermath of the DTx products must COVID-19 pandemic is likely to trigger another comply with ten rigorous 75,000 deaths of despair from drug abuse, alcohol patient-centered core principles. misuse, or suicide. The United States will be unable to meet this heightened need for mental health services if we rely solely on traditional sources of counseling and treatment.

Technology adoption is essential to a health care system under duress. During coronavirus isolation periods, Americans of all ages and backgrounds quickly adopted the use of a wide range of technologies to continue working, maintain connections to friends and family, and connect with health care services. Many clinicians embraced telehealth and other technologies for the first time to meet with and serve patients, to the extent that telehealth visits in the United States increased 4,347% in March 2020 compared to March 2019. Overall, patient and clinician experiences have been favorable, with 74% of patients reporting high satisfaction with telehealth usage and 57% of clinicians viewing it more favorably than before COVID-19. While the immediate scaling of telehealth has been very successful, further benefits could result with additional technologies such as remote monitoring tools and digital therapeutics being layered into the broader care ecosystem. With these integrations, clinicians will be able to treat patients across existing language barriers (e.g., Spanish and other non-English speaking populations), in addition to having access to objective physical measurements and clinical outcomes to better assess and optimize therapy, thus moving beyond patient recollection and perception of health status as sole sources of clinical evidence.

Behavioral & Mental Health. Digital therapeutics may also dramatically improve access to mental health treatment. Since they are often provided in the context of traditional or novel clinician-delivered care models, DTx products can expand clinicians’ ability to care for patients in and beyond traditional settings by providing clinical grade, personalized therapies to patients in their home environments. This has enabled health systems to begin filling critical gaps in patient care. Clinical research has demonstrated the success of numerous DTx products in treating mental health conditions. For example: SilverCloud Health’s DTx product, Space from Depression, demonstrated that 60% of patients with a diagnosis of depression achieved recovery criteria after three months of usage. Digital Therapeutics to page 314

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Immediate value of digital therapeutics Building on the ease of product scalability and access through patientowned devices, the lessons learned during COVID-19 demonstrated that DTx products can more easily reach high-risk, rural, and underserved communities that often lack access to health care services even during the best of times. Among numerous other patient benefits (see https://tinyurl. com/mp-dtx-benefits), these products provide patients and clinicians with actionable real-world insights, introduce a new degree of flexibility for patients who may have difficulty leaving work or school for medical appointments during traditional office hours, and increase the number of languages in which active treatment may be delivered. Chronic Diseases. Clinical research has demonstrated that digital therapeutics are highly effective for health conditions such as asthma and diabetes, where prominent disparities exist. Propeller, a digital therapeutic developed for asthma, has demonstrated a 50% reduction in emergency room hospitalizations and a 63% increase in asthma control. Several effective digital therapeutics are available for patients with diabetes. BlueStar, Welldoc’s DTx product for Type 1 and Type 2 diabetes, lowers A1c levels on average between

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SENIOR CARE

The Age Friendly Network Making communities livable for seniors BY WILL PHILLIPS

To date, more than 500 towns, cities and counties and 6 states have enrolled in the Network – going through a rigorous five-year cycle of continuous improvement that hinges on a robust assessment of community needs. That assessment is a critical first step in the process that drives the development of a comprehensive community action plan. Enrollment in the Network is not a certificate of achievement or a gold star program, but rather a commitment to become more age-friendly by focusing on and taking action to address the needs of older adults.

The Network provides cities, towns, counties and states with the resources to become more age-friendly by tapping into national and global research, planning models and best practices. Membership in the Network means that a community’s elected leadership has made a commitment to actively work with residents and local advocates to make their community an age-friendly place to live.

Members of the Network work to make improvements in their community to all or some combination of eight domains of livability that include outdoor spaces and buildings, transportation, housing, opportunities to participate in social activities, respect and social inclusion, civic participation and employment, communication and information, community support and health services. The common thread among the enrolled communities and states is the belief that the places where we live are more livable, and better able to support people of all ages, when local leaders commit to improving the quality of life for the very young, the very old, and everyone in between.

ll of us are aging and the population of the United States is aging rapidly. By 2035, the number of adults older than 65 will be greater than the number of school-age children. In Minnesota, we hit that milestone this year. That’s why since 2012, staff and volunteers have been working throughout the nation to engage and mobilize communities, share expertise, and deliver technical assistance to the towns, cities, counties and states by creating the AARP Network of Age-Friendly States and Communities (the Network). This work is part of a broader effort to make communities more livable, as well as AARP’s ongoing work to support older adults to live their best lives at every age.

In Minnesota, nine communities have officially enrolled in the Network and are at varying stages of work. While Minneapolis, Alexandria, Northfield and Maple Grove are in the process of implementing their Age-Friendly action plans, Hennepin and Olmsted Counties along with Brooklyn Park, St. Cloud and Princeton are newly enrolled and beginning the process of assessing community needs. To date, the work of these communities has been deliberate and impressive.

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Even before the pandemic hit, the value of pursuing a more “age-friendly future” was evident. A 2019 survey of Network members revealed that 60 percent of enrolled communities in the later stages of their multi- year effort reported having achieved a change in public policy — most frequently in housing, transportation, outdoor spaces and buildings, and health and community services. The same survey revealed that 34 percent achieved a private-sector investment or action, and 85 percent described other successes, such as integrating an age-friendly lens into strategic planning and increasing collaboration within the community. In the midst of COVID-19, the challenges of isolation, access to food and services, financial stresses, and the importance of accurate and timely information have become even more acute for older Minnesotans. As an example, “The Pandemic Effect: A Social Isolation Report” – a just-released study conducted by AARP Foundation in collaboration with the United Health Foundation, found two-thirds of adults report experiencing social isolation and high levels of anxiety since the beginning of the pandemic. The report notes that many of those affected have not turned to anyone for help, perhaps because many don’t have reliable social support networks.

Effective Support Networks Because of their emphasis on cross-sector partnerships, communication, volunteerism and their focus on older residents, age-friendly communities have served to enhance community response to problems like social isolation and others that have been exacerbated by the pandemic. Her are some examples: • Age-Friendly Maple Grove saw that the pandemic made affordable housing and accessible transportation more important than ever. Their work also pivoted in the midst of the pandemic with the community partnering with T-Mobile to launch a table program for older adults and helping to transition an existing “dial-a-ride” program to include food shelf and grocery delivery and expanding the program to nearby communities.

greater efficacy in community efforts. And while efforts are progressing and more communities are primed to enroll in the Network, there is also new interest in the State of Minnesota stepping up its efforts to become a better place for people to age.

In December of 2019, Governor Tim Walz signed Executive Order 19-38, which established the Governor’s Council on an Age-Friendly Minnesota and “formalized his commitment to making Minnesota the best state to live in at any age.” That Council, comprised of nine state agency representatives and six community members met throughout the spring and summer Where you live can even and in August delivered a set of recommendations to more dramatically impact the Governor, calling for the State to officially enroll people in middle age. in the Network and for the work to be funded and permanently established in law in recognition of aging as a strategic priority for Minnesota.

• In Northfield, the Age-Friendly group developed a telemedicine guide for elders to follow when meeting with doctors online, and as part of their focus on communication and information, they sent an emergency services guide to residents. • And in Alexandria, the Age-Friendly group set up a friendly caller and video chat program with Elder Network to combat the growing challenge of isolation and to help spread timely and accurate information. The nine Minnesota Age Friendly Communities are part of a larger, national network where best practices and lessons learned are shared – helping to ensure

Statewide Coordination Done right, this will ensure efforts are coordinated across state agencies to create a more age-friendly state. It will catalyze improvements at the local, community level by providing resources and removing barriers that have previously limited innovative approaches. The work will ultimately ensure that Minnesota can tap into the opportunities while simultaneously solving for the challenges of an aging population. The structures, services and community features that support older residents also help their children and grandchildren: transportation options, The Age Friendly Network to page 304

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SURGERY

Turning the Table Advancements in nerve repair saved surgical career BY PATRICK H. SMOCK, MD

My Story

atients undergo surgical procedures to repair peripheral nerve injuries every day. Most of the time I am the one in scrubs performing the procedure to restore a patient’s ability to move, feel or to even eliminate pain as the result of a nerve injury. Recently, after suffering a minor yet career-impacting injury, I found myself on the other side of the operating table.

Back in 2014, I was in a mountain bike race and suffered a fairly common injury, called a skier’s thumb. I made an abrupt stop and consequently dislocated my thumb and tore a nearby ligament. Believing that I was dealing with instability in my thumb alone, I quickly sought surgery to repair the ligament damage and put the whole experience behind me.

As an orthopedic surgeon with a specialization in hand, and upper extremity injuries, I am well-acquainted with the intricacies of the nearby nervous system. However, I never considered how a nerve injury would impact my ability to perform surgery or how a procedure I frequently perform truly affects quality of life, for both myself and my patients. I’ve now had the unique experience as both the surgeon and the patient and the benefit of being on the receiving end of advancements in nerve repair. It has granted me a renewed perspective on my decision to become a surgeon. I hope that my story will help fellow health care professionals to fully understand options when dealing with nerve injuries after a traumatic injury —or a minor injury that has major repercussions, like mine.

As my recovery progressed, I started to notice loss of sensation in my thumb and forefinger and also began to develop significant pain in that region of my hand. It quickly became evident that I had also sustained nerve damage in the accident, something I often see in my own practice. As a surgeon, I rely on proper dexterity and feeling in my fingers and began to worry about the implications this impairment could potentially have on my profession. I found myself in a situation I had never before considered: the permanent loss of feeling in one of my fingers. Fortunately, I understood the importance of seeking treatment in a timely manner and quickly connected with a friend, fellow surgeon and former colleague who helped determine that a neuroma, a painful tangle of broken and damaged nerve fibers, had developed in my radial sensory nerve due to the accident months prior, but had only recently started to

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cause concerning symptoms. I had surgery to remove the neuroma, and my surgeon used an Avance® Nerve Graft, a human nerve allograft, to bridge the nerve gap and allow it to regrow. Within a few months, I had regained all sensation in my fingers and the pain had dissipated.

In addition to a loss of sensation or inability to move an area of the body, patients with nerve damage may complain of chronic pain, sharp spasms, burning sensations, or extreme sensitivity to touch and temperature.

Chronic pain is particularly important to keep in mind. Often, the first course of treatment for patients with chronic pain is to manage the symptom through pain medication or noninvasive treatments such as massage treatments, acupuncture and physical therapy. Many of these treatments offer temporary relief, but do not fix the source of the pain which could be an injured nerve. If a patient’s pain lasts greater than I found myself on the other side of the operating table. three months after an injury or surgery, there is a chance it may be due to a nerve injury and should be further evaluated by a physician specializing in nerve repair.

Because of this procedure, I was able to achieve a positive outcome and was back to operating with an increased appreciation for the impact a nerve injury can have on a patient’s life. As a father of five, I strive to remain as healthy as possible, and while this was a minor injury, there was never a doubt that it needed to be corrected, for my family and for my career.

Recognizing and Repairing Damaged Nerves

Patients who have suffered a nerve injury often land in a primary care physician’s office seeking help for their symptoms. It’s important for primary care physicians to have a working understanding of nerve damage and be able to recognize the symptoms so they can quickly direct their patients to a nerve specialist who can help. Nerves can commonly be injured as the result of falls, fractures, glass or knife cuts, car accidents where limbs are stretched or badly bruised, gun shots, or even overuse injuries like carpal tunnel syndrome. It’s also possible that a nerve may have been unintentionally damaged during a previous surgery and the patient later develops nerve damage related symptoms.

Timing is also essential – damaged nerves can be surgically repaired, but the window of time for the best surgical outcome is limited. Patients with potential nerve damage should be sent to a nerve specialist as quickly as possible after injury.

Advancements in Nerve Repair It’s also important to understand what nerve repair can look like for our patients. For me, as both a nerve surgeon and a patient, the advancements in nerve repair have been particularly interesting as I personally benefited from an emerging technology that helped to improve my recovery. Turning the Table to page 284

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BEHAVIORAL HEALTH

Physician Moral Distress A reckoning with unmet needs BY TIMOTHY J. USSET, MDIV, MPH, MIKE KOOPMEINERS, MD AND JOSHUA T. MORRIS, PHD, BCC

ystemic change in health care delivery to improve clinician well being, and thereby patient outcomes, has long been overdue. The need for it now has become even more acute. Physicians were experiencing well-documented rates of burnout, as high as 60%, before the pandemic began. New workplace realities have multiplied the complexities of this problem. These factors include caring for individuals who knowingly or unknowingly have COVID-19, concerns they will contract the virus and infect loved ones, wondering whether their institution will provide the necessary PPE, juggling child care, elder care, personal paid time away from work if they get sick, wrestling with furloughs and a struggling economy, and the numerous issues around the COVID19 vaccination. Add to this the pressures that arise leaving work to have conversations in the community with people about the efficacy of masks and shelter-in-place protocols. Physicians and other healthcare professionals, often lauded as “heroes” continue to experience the above stressors in ways that are further complicated by inconsistent political responses and lack of appropriate response from society at large. Day to day decisions people make about mask wearing and social precautions are the front line of the pandemic.

Multivalent Factors At minimum, the reality of the pandemic moves beyond burnout to include the paradigms of moral distress and moral injury, considerations that are being amplified for physicians during the pandemic. Moral distress takes place at the intersection of recognizing the appropriate clinical course of action, but due to internal or external constraints, being unable to take that action. The literature on a complementary term to moral distress; moral injury, defines that in high stakes situations, and from key leadership personnel, there is a betrayal of what’s right or the experience of acting in ways contrary to individual moral value. It is precisely through naming the betrayal of what is right and in acknowledging the moral stress of working in the pandemic that we can affirm what physicians are experiencing. Further, the totality of the stressors physicians and other healthcare professionals are carrying needs a reckoning. This stress leads directly to emotional and physical harm. Many studies aptly identify elements of how our health cares delivery system works that contribute to burnout. Wellmeaning healthcare advocates and administrators encourage workers to practice self-care, take respite, and focus on one’s self in preparation for taking on this virus. Individual practices of centering oneself and self-care are, of course, vital for caregivers however treating a robust systemic failure with individual manners of reliance does not adequately address the issues.

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DECEMBER 2020 MINNESOTA PHYSICIAN

What is needed, or at least has the potential to move the industry in the right direction, is for the community of physicians to remain tethered in solidarity. There are exceptions, but our health systems will not be making drastic changes overnight to bring about healthier work environments for physicians. The dark irony of how slowly vital issues in our healthcare and political systems are addressed is found in the need for individual and collective practices among physicians to support and sustain one another. Physicians can not fix the problems of burnout, moral distress, or moral injury through just self-care, but can take steps toward maintaining meaning and purpose amid the increased challenges of their work to weather this storm.

Making meaning and valuable practices Resilience may be a protective factor against things such as burnout or moral distress, but it is a not vaccine. High levels of burnout have been found even among “resilient” physicians. In concert with building one’s capacity to thrive, holding and fostering one’s capacity to resist despair and bitterness during incredible adversity is a necessary and possibly more appropriate way of framing resilience during the pandemic. There are practices and interventions that have been found to be effective in addressing the impact of morally challenging events. Service members and veterans frequently experience guilt and/or shame following morally challenging or ambiguous circumstances. Similar to those in the military, physicians may also experience guilt and/or shame following the stress of practicing medicine during the pandemic. Not to conflate or equate military experience with practicing medicine but there is a similarity

in guilt/shame responses that has been studied extensively and has yielded coping techniques that present options for physicians. Specifically, there are practices that have been integrated into new wave interventions to facilitate those who have experienced moral injury.

Another method is to gather a small group (3-4) of peers that you trust and schedule a time-share about what is most stressful in your practice right now. This should be in a semi-structured environment that allows everyone to speak briefly, then receive and offer feedback to others in the group. A recommended outline could include:

Moral injury can arise from the challenges Step 1: 30 seconds to share something of treating patients in the resource-constrained environment of the pandemic. The way in which distressing in your practice physicians are taught to and value practicing Step 2: 15 seconds of silence medicine has been challenged by the utilitarian processes that were implemented to manage scarce Step 3: 3 minutes for feedback from other The reality of the pandemic moves beyond burnout. resources. For some physicians, these dilemmas members of the group create a sense of guilt over “not having done Step 4: 1 minute to respond to the feedback enough” for their patients. This is a prime example from the person that originally share of moral injury and there are several effective Repeat steps 1-4 for each person present. techniques to process this experience. One method is the practice of writing brief letters to a present or The purpose of this group isn’t to solve all of the deceased compassionate person. This should be a person you trust to act with problems in medicine or our healthcare system, but to connect with and receive compassion toward you. The purpose of the letter is to briefly share what feedback from other professionals. The outline above could be completed in you are finding distressing in your practice and what you would like to do as little as 15-20 minutes for meetings of three to four people. Hearing from differently about it. If the letter is written to someone that is deceased (i.e. a others can help identify other perspectives and moral contexts that can foster trusted grandparent, sibling, parent or friend), the next part of the process your “capacity to resist” the pull of shame, despair, or bitterness. In addition is imagining how that individual might respond to you in a compassionate to providing insight on guilt or shame, the above practices work to address way. If the letter is written to someone still living, you can setup a time to loneliness and isolation. By connecting with trusted individuals in or outside share it with them to receive their feedback. If you would prefer not to share it, you can imagine that person’s compassionate response to you. Physician Moral Distress to page 224

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3Physician Moral Distress from page 21 or chaplains that are available to support clinicians. In the event internal staff are not available, EAP programs are another option for seeking shortterm support. Physicians Serving Physicians has been providing support to physicians experiencing substance use concerns since 1981. The Physicians Wellness Collaborative (PWC) was created in 2020 as a program of PSP to reflect the expansion of PSP’s services to include physician mental health and wellness. The PWC It is important for physicians offers peer support and mental health services to remember and maintain to physicians (at no cost to them) that prefer to their agency. work with resources outside of their employer. In these unique times it is important for physicians to remember and maintain their agency, ability to make meaning, and practice whole-heartedly in the midst of incredibly challenging circumstances.

of the profession you can tend to your ability to practice compassion toward yourself and others.

When/Where to seek more formal support?

When it comes to seeking support from peers or professionals, what we call the various stresses and challenges of medical practice is less important than noticing their impact. Physicians need to have an active sense of what their equilibrium looks like in their practice. This includes everything related to professional practice and also time spent with family and other life-giving activities. What changes have been especially noticeable during the pandemic? Less time with family? Drinking more? Spending more time in the EHR? Changes in equilibrium are not in and of themselves problematic, but unrecognized changes can lead to new work/ life equilibriums that are at odds with one’s values. On the more serious side they could result in medical errors, adverse patient outcomes, and negatively impact relationships with family and friends. Though stigma around seeking help for behavioral concerns is still alive and well, even among clinical disciplines, this should never discourage any physician to take those steps, or to recommend them to a colleague who they may know is suffering. Many systems have internal behavioral health staff

Timothy J. Usset, MDiv, MPH, is the Executive Director of Physicians Wellness Collaborative https://psp-mn.com/

Mike Koopmeiners, MD, is the Medical Director of Physicians Wellness Collaborative.

Joshua T. Morris, PhD, BCC, is the Chaplain at Children’s Mercy Hospital, Kansas City.

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DECEMBER 2020 MINNESOTA PHYSICIAN

Peter Schultz, MD, MPH Medical Director Nura Pain Clinics R. Scott Stayner, MD, PhD Medical Director Nura Surgery Centers David Schultz, MD Chief Executive Officer Nura Pain Clinics

1. Chronic pain doesn’t take holidays. Although the COVID-19 pandemic has captured the headlines, chronic pain does not relent. According to the CDC, high-impact chronic pain (pain that interferes with work or life most days or every day) affects approximately 20 million U.S. adults.

2. Opioids are a problem. They can also be part of the solution. According to the CDC, opioid overdose is now the leading cause of injury-related death in the United States. Yet opioids have a rightful place in treating chronic pain, as some patients achieve life-changing improvement with minimal side effects on long-term opioids. Even at high dosage levels, opioids do not harm the body’s organs, unlike NSAIDS and acetaminophen. And thanks to the micro-dosing capability off ered by implanted spinal drug pumps, many of the most challenging cases can be treated effectively without risk of addiction.

Our thoughts on chronic pain…

3. There is no silver bullet. One of the challenges in treating chronic pain is the patient’s sometimes-overwhelming desire for a silver bullet, a “cure” or a magic button to turn oﬀ their pain. While that desire is understandable, in complex chronic pain there is rarely a single perfect answer. At Nura, we’ve found that a comprehensive approach which addresses the physical and psychosocial components of chronic pain is the best solution. So in addition to earning national recognition for leadership in implantable pain technology, we oﬀer behavioral counseling, physical therapy and opioid management, all designed to help the most challenging pain patients.

If you have a patient struggling with chronic pain and you’d like to discuss the case, please call our Provider Hotline at 763-537-1000. If the situation is urgent, we will do our very best to see your patient the same or next day.

MINNESOTA PHYSICIAN DECEMBER 2020

BEHAVIORAL HEALTH

An Epidemic Within a Pandemic System-Level Changes for Physician Wellbeing BY MICHELLE D. SHERMAN, PHD LP ABPP, ADAM SATTLER, PHD LP, BARBARA CARVER PSYD, LP, ROSEAN BISHOP, PHD LP, JENNIFER NELSON ALBEE, MSW, LICSW

n recognition of research showing over 50% of United States physicians report significant symptoms of burnout, in 2017 the National Academy of Medicine created the Action Collaborative on Clinician Well-Being and Resilience. This program aimed to increase attention to the epidemic of clinician burnout and to advance researchbased solutions to provide support. Similarly, conceptual models have been offered (e.g., Shanafelt & Noseworthy, 2017; Shapiro et al., 2018) identifying key drivers of burnout, organizational strategies to mitigate burnout, and systems-level interventions. Efforts such as these are important and necessary, but broad application to everyday practice and measurable impacts have yet to be seen. Then, the COVID-19 pandemic suddenly and intensely hit our world in March 2020, therein exposing many societal issues (e.g., health/wealth inequities along racial lines) that adversely impact physician well-being and the patients they serve. Medical school did not prepare anyone for the challenges 2020 would bring to the healthcare system and our patients.

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DECEMBER 2020 MINNESOTA PHYSICIAN

As psychologists/social workers embedded in family medicine residency programs at four large healthcare systems across Minnesota, we see and truly hurt for our physician colleagues serving on the front lines of the COVID pandemic. The levels of stress are palpable. Emerging research is documenting healthcare providers’ elevated rates of insomnia, anxiety, and depression (Pappa et al., 2020). Anecdotally, we hear some colleagues questioning if they want to continue their careers as physicians. Many have taken pay cuts over the past year due to financial challenges faced by healthcare. Witnessing such high rates of illness and death can be traumatic, and we worry about short-and long-term trauma-reactions including but not limited to PTSD, increased rates of self-harm and suicide, increased rates of substance use disorders and overdose, moral injury, and more. So, we see and honor physicians’ exhaustion, fear and anxiety, anger, sadness, sense of feeling overwhelmed and inability to do their jobs due to shortages of resources, and grief at lost colleagues, family, and friends. Of note, these struggles are not exclusively due to the pandemic, and they will not spontaneously remit once this virus is under better control. We thank physicians for their sacrifices, commitment, and courage during this incredibly stressful time.

Well-intended efforts Across our healthcare systems, we have seen many well-intended efforts to support the healthcare workforce. EAP services, webinars, free pizza, resource toolkits teaching coping skills, emails offering appreciation….many of these individual efforts are important and definitely may be helpful to some people. However, for many physicians, these efforts are not only falling flat but are actually offensive. For example, a wellness guide was emailed to physicians in one of our systems; residents found the suggestions of deep breathing and exercise to be really missing the mark in light of their current levels of stress and pain. Instead of experiencing the well-intended resource as helpful, it was a source of derision and mockery. Offering such resources without acknowledging the broader systemic issues affecting physician well-being has backfired; efforts such as this may be inflaming physicians’ longstanding and deeply held frustrations with the system. Further, many overwhelmed physicians experience resilience suggestions (e.g., exercise more, meditate more) as something else that they aren’t doing well – thereby worsening their well-being rather than improving it.

Steps for making change We are committed to work alongside our physician colleagues in the journey ahead to build the healthcare system back to a place that is better than prepandemic time. This rebuilding may provide an opportunity to thoughtfully examine some long-standing systemic issues that impact well-being. The solution is NOT more resilience training focused at the individual level. Physicians are resilient people. Below are some specific systemic steps we urge healthcare leaders to consider to effectively support physicians. Ensure all healthcare providers have sufficient PPE, regular testing, and early access to the vaccine. Allocation of sufficient resources to help keep our frontline providers safe is essential. A recent article (Chin et

al., 2020) found that routine testing of asymptomatic providers substantially reduces the risk of outbreaks. However, to the best of our knowledge, this is not routinely occurring in any of our healthcare systems. Professional sports teams, yes. Front line doctors, no. We are grateful that states are vaccinating healthcare providers first so that they can stay well physically and care for their communities. Make confidential, free mental health services easily available – on work time. Our physician colleagues have shared that this is the most stressful time of their careers, and many desire psychotherapy. However, carving out time during their already extremely busy schedules is hard, especially when balancing this with family needs. Counseling must be made accessible, and barriers need to be eliminated.

Foster an intentional culture of appreciation, connection, and focus on meaning in work. Although leaders need to carefully consider and respond to patient complaints and system breakdown, is equal (or more) attention paid to patient compliments, team successes, and bolstering team cohesiveness? Everyone in the clinic benefits when team members at all levels make intentional efforts to affirm, celebrate, and build relationships.

In addition, encouraging physicians to reflect and draw upon the reason they chose the career of Counseling must be made medicine and the meaning they derive from work accessible, and barriers can be useful. How does each person’s contribution need to be eliminated. connect to the broader clinic’s values and mission? Although the drive home from work can be a natural time to focus on the day’s challenges, can leaders encourage intentional reflection on one positive interaction or progress on a project? In Reduce the frequency and burden of non-essential demands on phyacademic institutions, preceptors can specifically encourage trainees to reflect sicians’ time. After a busy clinic day or shift in the hospital, physicians on one thing they learned and one patient they positively impacted that day. often spend evening or weekend time attending to administrative tasks. Eliminate state medical boards’ restrictions on licensure for physicians Leaders can strive to minimize such burdens by limiting emails to those seeking therapy or experiencing mental illness. Asking for help for which are absolutely essential, combining and reducing required trainings, mental health concerns is hard, especially for physicians who dedicate their and releasing expectations for immediate responding when not on call. Simcareers to helping others. We need to eliminate this substantial barrier of ilarly, increasing meeting efficiency and shortening required meetings can fear of negative licensure repercussions of seeking help. Clearly the medical be very helpful; structuring meetings such that participants attend only the parts that apply to their role is useful.

An Epidemic Within a Pandemic to page 264

MINNESOTA PHYSICIAN DECEMBER 2020

3An Epidemic Within a Pandemic from page 25 boards have a societal duty to ensuring physicians are competent and able to provide care to patients, but the current stringent rules in many states deter physicians from seeking much-needed mental health care. Dedicate funding to research and clinical initiatives to understanding and appropriately addressing physician well-being. We applaud legislation such as the The Dr. Lorna Breen Health Care Provider Protection Act (S. 4349; HR 8094) which aims to “reduce and prevent suicide, burnout, and mental and behavioral health conditions among health care professionals” by grants, training, service provision, public health campaigns, and research. Funding to accomplish these goals is imperative. Prevention and early intervention approaches must be developed and evaluated. Begin this mindset shift in early years of medical training. According to the Association of American Medical Colleges, the number of applicants to medical schools is up 18% in 2020 compared to 2019. Some have termed this the “Fauci effect,” as Dr Fauci’s leadership has inspired people to want to serve as physicians (Marcus, 2020). Given the anticipated shortage of physicians with large numbers retiring in the next decade, recruiting and training physicians is important. However, medical school and residency are known to be extremely stressful times with elevated rates of mental illness. Thus, systematic changes are necessary to recruit, retain, and graduate physicians who will choose to stay in this stressful career.

Many of these long-standing problems require system-level changes that take commitments of time, energy, and money. Our physician colleagues are exhausted and overwhelmed by caring for patients during this extremely difficult time. We need to broaden the locus of responsibility for physician well-being from an individualistic (physician, heal thyself) to a broader communitarian response. Just as a vaccine is offering hope for gaining some control over COVID, a substantive transformation of the healthcare system is necessary to sustain and offer hope for our greatest asset, our healthcare providers. Michelle D. Sherman, PhD LP ABPP, North Memorial FMR Program, University of MN Adam Sattler, PhD LP, North Memorial FMR Program, University of MN.

Barbara Carver PsyD, LP, St Cloud FMR Program, CentraCare, University of MN. Rosean Bishop, PhD LP, Mayo Clinic/University of MN FMR Program.

Jennifer Nelson Albee, MSW, LICSW, Duluth FMR Program, Essentia Health.

V Alzheimer’s is now an approved condition V

HAVE YOU REGISTERED WITH THE MINNESOTA MEDICAL CANNABIS PROGRAM? Registration can be done online; there is no fee and it takes only a few minutes. Visit the registry website: mn.gov/medicalcannabis Your account will provide access to medical cannabis purchasing information from patients you certify. Once you are registered, you will be able to certify patients with a variety of conditions, including: • Cancer, Glaucoma, Tourette Syndrome, HIV/AIDS, and ALS

• Inflammatory bowel disease, including Crohn’s disease

• Seizures, including those characteristic of Epilepsy

• Terminal illness, with a probable life expectancy of less than one year

• Severe and persistent muscle spasms, including those characteristic of MS

• Intractable Pain

• Obstructive sleep apnea

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• Autism

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Many patients have reported improvement in their health status from medical cannabis — some describing dramatic improvements. Smoking cannabis is not allowed under the program. Visit our website for educational resources about cannabinoids and the endocannabinoid system and for scientific literature on the efficacy of medical cannabis in treating certain conditions.

See our website for a detailed first year report. mn.gov/medicalcannabis

DECEMBER 2020 MINNESOTA PHYSICIAN

MINNESOTA PHYSICIAN DECEMBER 2020

3Turning the Table from page 19 In the past, one of the only options for nerve repair was to harvest a nerve from another site on the patient’s body—typically the leg in order to repair the injury. This procedure caused a patient to have two surgical sites in addition to often permanent and bothersome numbness at the harvest site. Today there is another option. Axogen, a pioneer in peripheral nerve repair, has developed the Avance® Nerve Graft which offers clearly documented improvements in the way nerves are repaired and eliminates the potential comorbidities associated with a second surgical site. Avance Nerve Graft has since been widely used to help surgeons successfully repair damaged and injured peripheral nerves across the body. There are over 100 published clinical papers describing the use of Avance® Nerve Graft for the repair of sensory and motor nerves in the hands, arms, face, torso and lower extremities.

Moving Forward While I was aware of these medical advances prior to my injury, I have become more of an advocate for the technology ever since, using it frequently when working with patients suffering from nerve damage. I recommend the same procedure I had done and the same technology that helps me do my job to patients with similar or even much more severe injuries than myself. My goal is to help patients return to normal life as soon as possible. I find this particularly valuable when it comes to my patients who are suffering from pain. While I was able to connect my nerve pain to my

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DECEMBER 2020 MINNESOTA PHYSICIAN

traumatic injury relatively easily, many chronic pain patients may not realize a neuroma is causing the issue and that it’s something that can be surgically repaired. It’s important to know that if a patient’s pain is still present three months after a traumatic injury or a surgery, there is a good chance a nerve injury may be to blame and they should be evaluated by a nerve specialist like myself. If a neuroma is the cause of the pain, through surgical nerve repair, patients have an opportunity to live pain free and resume a more normal life, and we should do everything our power to give that to them. Nerve damage, however small the originating injury, can cause excruciating pain, put lives on hold and jobs at risk when not addressed properly in a timely manner. I stress the importance of nerve repair procedures to my patients daily. My job is dependent on the proper function of my hands. You don’t truly realize the importance of the ability to use your hands until you lose it. Had I not recognized the cause of the pain and numbness as a nerve injury and sought care in a timely manner, my situation could have become more permanent. Fortunately, nerve repair technologies are widely studied, and we now have groundbreaking options to help ensure these injuries are temporary. My experience on the operating table heightened my passion for my career choice and supplemented my goal to provide my patients the best options for their recovery. Patrick H. Smock, MD, is an orthopedic surgeon specializing in hand, wrist and elbow injuries at Allina Health Orthopedics in St. Paul, MN.

Patients with regenerative medicine questions?

Regenerative medicine focuses on the body’s natural ability to repair, replace, and regenerate damaged or aging tissues. At MINNESOTA REGENERATIVE MEDICINE (MRM), a specialty clinic of HOGUE CLINICS, autologous bio-cellular agents such as platelet-rich plasma (PRP), fat aspirate concentrate (FAC), and bone marrow aspirate concentrate (BMAC) are used to treat degenerative conditions. To ensure proper placement, ultrasound or fluoroscopy guidance is used when clinically indicated during regenerative medicine treatments.

Regenerative medicine treatment categories at MRM include: • Bio-cellular treatment of OSTEOARTHRITIS and CHRONIC TENDINITIS (all peripheral joints & tendons, excluding spine) • Bio-cellular hair restoration for HAIR LOSS, HAIR THINNING, EARLY SCALP BALDING • Bio-cellular treatment of ERECTILE DYSFUNCTION, PEYRONIE’S DISEASE, and PENILE GIRTH ENHANCEMENT

8 Hogue Clinics locations in Minnesota www.mregm.com • (763) 447-2500 or Toll Free (866) 219-4699 MINNESOTA PHYSICIAN DECEMBER 2020

3The Age Friendly Network from page 17 safe, affordable places to live, a community commitment to health and wellness and opportunities to stay engaged and productive. Whether at the state or local level, supporting Age-Friendly States and Communities ensures that we are moving in tandem with leading thinkers on the social determinants of health by creating what has served as a potent guiding framework to effect local change — in health, well-being, and engagement — all through changes to the built environment as well as social supports. We’ve long known about the long-term health and income disparities that can be traced to where you were born; but a recent AARP study demonstrates that where you live can even more dramatically impact people in middle age. The report, How Growing Geographic and Racial Disparities Inhibit the Ability to Live Longer and Healthier Lives, notes that people living in healthier communities in middle age “are benefitting from increasing longevity, while the residents of the worst-performing counties are not given the same opportunity”. Addressing the health, economic and social disparities that have persisted in our state for too long must be a priority for any age-friendly initiative. Fortunately for all of us, some of the most effective age-friendly community initiatives are those that spring forth from the ground up. While some age-friendly initiatives begin with mayors and city councils, just as many if not more are pushed by engaged citizens and grassroots organizations. Research into the champions and leaders of age-friendly community work shows that there is a role for everybody.

Getting Involved As physicians and health care professionals you can play a vital role in creating community-level change by engaging in the communities where you live. Stay informed, spread the word, get involved and push for change. • Take some time to browse the robust set of resources at aarp.org/ livable for everything from the basics of the Network to DIY guides around how to assess the walkability of your neighborhood streets, to examples of how communities are addressing everything from housing to public spaces. • Sign up for our Minnesota-specific AARP Livable Communities newsletter by emailing a request to jhaapala@aarp.org. • Assess your community’s livability features and explore where there may be gaps and opportunities for improvement by exploring the AARP Livability Index at livabilityindex.aarp.org. • Push for change at the local and state level by informing community leaders of the benefits of more livable, age-friendly communities and ask them what they are doing to address aging – including enrolling in the Network. • Connect with state legislators to make them champions for healthy aging. Will Phillips, is the state director for AARP Minnesota, a non-partisan, nonprofit social impact organization with a membership of more than 650,000 Minnesotans over the age of 50. Will can be reached at wphillips@aarp.org.

Unique Practice Opportunity Join an established independent internal medicine practice Be your own boss in a collaborative business model with a healthcare philosophy that puts patients first and allows physicians to have complete control of their practice. The specialties we are looking for are: Internal Medicine, Family Practice, Preventive Medicine, Cardiology, Dermatology, Allergist, or any other office-based specialty.

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PHYSICIAN Modifying cells to fight cancer BY VERONIKA BACHANOVA, MD, PHD

niversity of Minnesota Health is now among the few selected centers in the nation to offer two new immunotherapy drugs for the treatment of diffuse large B-cell lymphoma. Both drugs—Yescarta and Kymriah—are part of an emerging class of treatments, called CAR T-cell therapies, that harness the power of a patient’s own immune system to eliminate cancer cells.

Physician/employer direct contracting

CAR T-cell therapy involves drawing blood from patients and separating out the T cells. Using a disarmed virus, the patient’s own T cells are genetically engineered to produce chimeric antigen receptors, or CARs, that allow them to recognize and attach to a specific protein, or antigen, on tumor cells. This process takes place in a laboratory and takes about 14 days. After receiving the modification, the engineered CAR-T cells are infused into the patient, where they recognize and attack cancer cells. Kymriah received initial FDA approval in 2017 for the treatment of pediatric acute lymphoblastic leukemia. CAR T-cell therapy to page 144

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ith the continuing escalation of health care costs, large and midsized selfinsured employers are once again looking for an edge to manage their medical plan costs and their bottom line. They understand that they are ultimately funding health care as they pay for their population’s claims.

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Many of these employers have employed the same overarching set of strategies: shop for a new carrier that is willing to lower the administrative costs or underprice the risk, Physician/employer direct contracting to page 124

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3Digital Therapeutics from page 15 Big Health’s Sleepio showed that sustained sleep health can be achieved in 76% of users with sleep problems. A randomized controlled trial with Vorvida demonstrated significant improvements in patients with alcohol use disorder, increasing those with “low risk drinking patterns” from 7.5% at inception to 38.9% by the six- month mark. ReSET, a DTx product for substance use disorder, is able to double abstinence rates among individuals with opioid and other substance use disorders. Freespira demonstrated that approximately 88% of patients with Post Traumatic Stress Disorder (PTSD) experienced an alleviation of symptoms. Additionally, PTSD patients had a statistically significant reduction in CAPS-5 (Clinician-Administered PTSD Scale for DSM-5) at two months post-treatment, with 50% in remission at six months.

What’s next? As with any new category of medicine, the rewards and risks must be intensely studied to appropriately guide patients, clinicians, and health systems through the development and adoption phases to ensure quality outcomes. Stakeholders across the digital therapeutics spectrum have made significant steps in terms of product design, evaluation, and meaningfulness in the context of patient care. There is still much to be done across the broader health care industry to ensure that these products are appropriately represented in clinical guidelines, covered alongside other medical treatments, and delivered at scale to patients across the world.

Advances made within other sectors of the digital health technology landscape, such as telehealth, need to be expanded to include DTx products. Interoperable platforms must be further developed to enable greater fluidity between monitoring, diagnostic, and therapeutic tools, while providing an increased ability to reach target populations. Digital therapeutics can produce significant personal and public health benefits. Product quality, efficacy, usability, and appropriateness are of paramount importance. The Digital Therapeutics Alliance (DTA) is committed to advancing these principles and working with health care decision-makers to ensure that industry education and convening efforts directly support patients, caregivers, and clinicians as they face critical changes in how health care is delivered during and beyond this pandemic era. Megan Coder, PharmD, MBA, is executive director of the Digital Therapeutics Alliance (DTA). Dr. Coder graduated from the University of Wisconsin—Madison School of Pharmacy and completed an Executive Residency in Association Management & Leadership with the American Pharmacists Association.

Christina Nyquist, is chief strategy officer at the Digital Therapeutics Alliance. Previously, she spent eight years as vice president, regulatory affairs with Aetna and 18 years with the Blue Cross Blue Shield Association.

Practice Opportunities throughout Greater Minnesota: Our nation faces an unprecedented number of individuals who having served their country now receive health care benefits through the VA system. We offer an opportunity for you to serve those who have served their country providing community based health care in modern facilities with access to world-leading research and research opportunities. We provide outstanding benefits with less stress and burnout than many large system policies create. We allow you to do what you do, best – care for patients.

Minneapolis VA Health Care System Metro based opportunities include: • Chief of General Internal Medicine • Chief of Cardiology • Cardiologist • Internal Medicine/Family Practice • Gastroenterologist • Psychiatrist

Ely VA Clinic

Hibbing VA Clinic

• Tele-ICU (Las Vegas, NV)

Current opportunities include:

• Nephrologist

Internal Medicine/Family Practice

US citizenship or proper work authorization required. Candidates should be BE/BC. Must have a valid medical license anywhere in US. Background check required. EEO Employer.

Possible Education Loan Repayment • Competitive Salary • Excellent Benefits • Professional Liability Insurance with Tail Coverage

For more information on current opportunities, contact: Yolanda Young: Yolanda.Young2@va.gov • 612-467-4964 One Veterans Drive, Minneapolis, MN 55417

•

www.minneapolis.va.gov MINNESOTA PHYSICIAN DECEMBER 2020

3Administrative Overload from page 13

outcomes needs to change. Administrative overload is one of the expensive aspects of our health care system, with no noticeable gain or benefit. The results are more expensive care, increased provider burnout and in some cases a worse patient experience. In the most damaging cases, the layers of administrative requirements create increased potential for adverse patient events.

as the department of health, fire marshal, and city officials. Systems that are larger and with multiple locations require complex training programs led by a safety officer and often a team focused on compliance and performance improvement.

An example of administrative overload in We need to determine the right balance of this area is the expensive burden of the various administrative services that support the triple and often overlapping audits that are required. aim, without creating redundancy, frustration, The U.S. could reduce Audits are usually associated with accounting and and unwieldy costs. There needs to be the same administrative spending even medical records, however, there is often an level for accountability and focus on quality in by 30 percent. even greater administrative overload in regulatory administrative processes as there is for patient requirements in auditing other functions such as care. Health care workers, whether administrative billing and coding, pharmacy and medication or direct care providers, are motivated to heal logs, medical equipment, server security and and help others. The shift of the regulatory focus networking permission and more. Each of these to processes and paperwork within healthcare is are critical functions and deserve astute attention, but often auditing detracting from quality care initiatives. Until we can get administration requirements are redundant, or in some cases irrelevant to a particular functions under better control and concentrate more on what really setting, yet still mandatory. Hospitals dedicate entire departments and matters in health care, costs will continue to increase as we compromise software applications to maintaining compliance in these areas, with little on actual quality. interoperability between the systems as the auditing checklists differ greatly.

Moving Forward

Todd Archbold, LSW, MBA, is a licensed social worker and the Chief

The U.S. health care system continues to evolve and is a world leader in many areas – but the increasingly disproportionate amount of effort spent on administrative tasks that don’t correspond to an increase in quality or

Executive Officer at PrairieCare.

Carris Health

is the perfect match

Carris Health is a multi-specialty health network located in west central and southwest Minnesota and is the perfect match for healthcare providers who are looking for an exceptional practice opportunity and a high quality of life. CURRENT OPPORTUNITIES AVAILABLE FOR BE/BC PHYSICIANS IN THE FOLLOWING SPECIALTIES: • • • • • •

Anesthesiology Dermatology ENT Family Medicine Gastroenterology General Surgery

• • • • • •

Hospitalist Internal Medicine Nephrology Neurology OB/GYN Oncology

Loan repayment assistance available.

FOR MORE INFORMATION: Dr. Leah Schammel, Carris Health Physician

DECEMBER 2020 MINNESOTA PHYSICIAN

Shana Zahrbock, Physician Recruitment Shana.Zahrbock@carrishealth.com (320) 231-6353 | carrishealth.com

• • • •

Orthopedic Surgery Psychiatry Psychology Pulmonary/ Critical Care • Rheumatology • Urology

YOU’D MAKE A REALLY GOOD DOCTOR IF YOU WEREN’T BEING AN OFFICE MANAGER.

Family Medicine & Emergency Medicine Physicians • • • • •

Great Opportunities

Immediate Openings Casual weekend or evening shift coverage Set your own hours Competitive rates Paid Malpractice

For more information, contact TSgt James Simpkins 402-292-1815 x102 james.simpkins.1@us.af.mil or visit airforce.com

763-682-5906 | 763-684-0243 michelle@whitesellmedstaff.com www.whitesellmedstaff.com

With more than 35 specialties, Olmsted Medical Center is known for the delivery of exceptional patient care that focuses on caring, quality, safety, and service in a family-oriented atmosphere. Rochester is a fast-growing community and provides numerous cultural, educational, and recreational opportunities. Olmsted Medical Center offers a competitive salary and comprehensive benefit package.

Opportunities available in the following specialties: • Active Aging Services - Geriatric Medicine/Palliative Care • Dermatology • ENT - Otology

• Family Medicine • Gastroenterology • Pediatrics

• Psychiatry - Adult • Psychiatry - Child & Adolescent • Rheumatology

Equal Opportunity Employer / Protected Veterans / Individuals with Disabilities

Send CV to: Olmsted Medical Center Human Resources/Clinician Recruitment 210 Ninth Street SE, Rochester, MN 55904

email: dcardille@olmmed.org • Phone: 507.529.6748 • Fax: 507.529.6622

www.olmstedmedicalcenter.org MINNESOTA PHYSICIAN DECEMBER 2020

3Corporate Culture in Health Care from page 11

the job of senior leadership; as important as quality, operations and financial management.

responsibility or accountability for the culture of the organization and its component parts, including the physician services organization. Governing boards of healthcare organizations “own” the culture of the organizations they lead. The physicians will look to the board as the designated body that holds the responsibility to ensure a stable, productive and mission-driven culture on behalf of all in the organization. With this in mind, what is the role of the health system board as it relates to the culture of the physician organization? Boards should think of their role as the “ keepers of culture” within in a framework of:

• Ongoing oversight: Governance holds the responsibility and accountability for ensuring that ongoing evaluation and development of organizational culture becomes an essential component of leadership, management and performance evaluation of the senior leadership team.

The culture of the organization is affected and reflected by physicians employed by the health system.

• Acceptance: Governance holds the responsibility and accountable for the culture of the organization, including the physician services organization.

In conclusion, members of governing boards cannot be expected to understand all there is to the leadership, operations and management of community health systems. They can be expected to fully engage with, and understand the cultures of the organizations they lead, including the cultural complexities of the embedded physician services organizations. The mantle of governance requires it.

• Understanding: Governance holds the responsibility and accountability to connect with the people of the organization to understand the state and status of the culture they lead, including direct engagement with employed physicians as participants in the process.

Daniel K. Zismer, Ph.D. is Co-Chair and CEO of Associated Eye Care

• Engagement and action: Governance holds the responsibility and accountability to engage with senior leadership and plan action required to ensure that culture development becomes integral to

Some of this article derives from administrations of the “CulturePulse” a

Partners Stillwater, Minnesota. He is also Co-founder of Castling Partners and a Professor Emeritus, Endowed Scholar and Chair School of Public Health, University of Minnesota.

proprietary organizational culture evaluation tool developed by D.K Zismer and B.J. Utecht.

A Place To Be Your Best. Dr. Julie Benson, MN Academy Family Physician of the Year

with a Mankato Clinic Career POSITIONS AVAILABLE:

OB GYN & FAMILY MEDICINE – Full-scope practice available (ER, OB, C-Section, Hospitalist, Clinic) • Independent/growing system • Located in the heart of lakes country, Staples, MN • Critical access hospital with 5 primary clinics and a senior living facility • 15 family medicine physicians and 16 advanced practice clinicians • Competitive salary, benefits, and sign-on bonus available Contact Michael Paul at 218.894.8633, or michaelpaul@lakewoodhealthsystem.com

Established in 1916, physician-owned and led Mankato Clinic is 100 years strong and seeking Family Physicians for outpatient-only practices. Over 50% of our physicians are involved in leadership positions and make decisions for our group. Full-time is 32 patient contact hours and 4 hours of administrative time per week. Four-day work week available. Clinic hours are Monday-Friday, 8 a.m.-5 p.m. OB is optional. Call is telephone triage, 1:17, supported by a 24/7 Nurse Health Line. Market-competitive guaranteed starting salary, followed by RVU production pay plan. Benefits include 35 vacation / CME Days annually + six holidays, $6,600 annual CME business allowance and a generous profit-sharing 401(k) plan. We’re just over an hour south of the Mall of America and MSP International Airport. If you would like to learn more about building a Thriving practice, contact:

Dennis Davito Director of Provider Services 1230 East Main Street Mankato, MN 56001 507-389-8654 dennisd@mankatoclinic.com

Apply online at www.mankatoclinic.com

DECEMBER 2020 MINNESOTA PHYSICIAN

URGENT RESOURCES FOR URGENT TIMES. In a pandemic, speed and access to information and resources are vital. Knowledge saves time, and you need all the time you can get to save lives. Introducing the COVID-19 Resource Center. Right here, right now, for you. On our website, you’ll find the latest information and resources for important topics like: • Telemedicine: including best practices and plain language consent forms • Links to infectious disease prevention guidance • Education and resources for healthcare providers on the front lines

You can access Coverys’ industry-leading Risk Management & Patient Safety services, videos, and staff training at coverys.com. All in one place, for our policyholders as well as for all healthcare providers. Thank you. For all that you are doing. You are our heroes, and we are here if you need us.

Medical Liability Insurance • Business Analytics • Risk Management • Education COPYRIGHTED. Insurance products issued by ProSelect® Insurance Company and Preferred Professional Insurance Company®

MINNESOTA PHYSICIAN DECEMBER 2020

Holly Boyer, MD

TRANSFORMING HEALTH & MEDICINE Leaders • Educators • Innovators

mphysicians.org

Minnesota Physician • December 2020

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SENIOR CARE The Age Friendly Network

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